US: selling to the worried well

US pharmaceutical companies have long known that the potential market for their products is limited by the finite number of sick people; so they have turned to the healthy for further expansion of their markets, using exploitative, fear-inducing advertising techniques.

Thirty years ago the head of one of the world’s best-known drug companies, Merck, made some over-candid comments. The aggressive chief executive, Henry Gadsden, who was close to retirement at the time, told Fortune magazine of his distress that Merck’s potential markets had been limited to sick people; he said he would have preferred Merck to be more like the chewing-gum manufacturer Wrigley, because then Merck would be able to “sell to everyone”; it had long been his dream to make drugs for healthy people. His dream has since come true.

The marketing strategies of the world’s biggest drug companies now aggressively target the healthy. The ups and downs of daily life have become classified as mental disorders, common complaints are transformed into frightening conditions, and more and more people are turned into patients. The $500bn pharmaceutical industry is changing what it means to be human, with promotional campaigns that exploit our deepest fears of death, decay and disease. Rightly rewarded for saving life and reducing suffering, the global drug giants are no longer content with selling medicines only to the ill. As Wall Street knows well, there is a lot of money to be made telling healthy people that they’re sick.

At a time when many of us lead longer, healthier and more vital lives than our ancestors, saturation advertising and slick awareness-raising campaigns turn the worried well into the worried sick. Mild problems are described as serious disease, so shyness becomes a sign of “social anxiety disorder” and pre-menstrual tension is turned into a mental illness, “pre-menstrual dysphoric disorder”. Just being at risk of an illness has become a disease in its own right.

The epicentre of this selling is the United States, home to many of the world’s largest pharmaceutical companies. The US has less than 5% of the world’s population but represents almost 50% of the global market in prescription drugs. Pharmaceuticals spending in the US continues to rise more rapidly than anywhere else, increasing by almost 100% in just six years, not only because of steep increases in the price of drugs, but because doctors prescribe more and more of them.

Vince Parry is the cutting edge of that global marketing. An expert in advertising who works from his mid-town Manhattan office in New York, Parry specialises in the most sophisticated form of medicine salesmanship: he works with drug companies to help create new diseases.

In an astonishing publication, The Art of Branding a Condition, he recently revealed the ways in which companies are involved in fostering the creation of medical disorders (1). Sometimes a little-known condition gets fresh attention, sometimes an old disease is redefined and renamed, and sometimes a whole new dysfunction is created. Parry’s personal favourites include erectile dysfunction, adult attention deficit disorder, and pre-menstrual dysphoric disorder (which is so controversial a classification that some researchers say it doesn’t exist).

Branding disease

With rare candour Parry explains how pharmaceutical companies take the lead, not just in branding such blockbuster drugs as Prozac and Viagra, but in branding the very conditions that create the markets for those drugs. Under the leadership of the drug marketers, Madison Avenue experts such as Parry collude with medical experts to “create new ideas about illnesses and conditions”. The goal, Parry says, is to give drug company customers around the world “a new way to think about things”. The aim is to make a direct link between the condition and the company’s medicine, to maximise its sales.

The idea that drug companies help to create illnesses may sound strange to the rest of us but it is familiar to industry insiders. A recent Reuters Business Insights report designed for drug company executives argued that the ability to create new disease markets is bringing in billions in soaring drug sales. One of the chief selling strategies, said the report, is to change the way people think about common ailments and to make natural processes into medical conditions. People must be convinced that “problems they may previously have accepted as, perhaps, merely an inconvenience” are now worthy of medical intervention.

Celebrating the development of profitable new disease markets, the report was upbeat about the financial future for the pharmaceutical industry: “The coming years will bear greater witness to the corporate-sponsored creation of disease.”

With many medical conditions, there is uncertainty about where to draw the line that separates the healthy from the sick. The boundaries that separate normal and abnormal are often highly elastic, they may differ dramatically from country to country, and they can change over time. Clearly, the wider the boundaries that define a disease can be drawn, the wider the pool of potential patients and therefore the bigger the markets for those making drugs.

The experts who sit down to draw those lines today often do so with drug company pens in their hands, and they are drawing the boundaries wider almost every time they meet. For example, they claim that 90% of elderly people in the US have a condition called “high blood pressure”, that almost 50% of women in the US have a sexual dysfunction called FSD, and that some 40 million US citizens should be taking drugs to lower their cholesterol. With help from headline-hungry media, the latest condition is routinely described as widespread, severe and, crucially, always treatable with drugs.

Alternative ways of understanding or treating health problems, and lower estimates of the numbers affected by those problems, are often ignored because of drug company promotions. The payment of money doesn’t necessarily buy influence, but many people believe that drug companies and doctors have become too close.

While the boundaries defining disease are pushed as wide as they can be, the causes of these supposed epidemics are defined as narrowly as possible. In the world of drug marketing, a major public health problem such as heart disease can be reduced to a narrow focus on cholesterol levels or blood pressure. The practical matter of preventing hip fractures among the elderly becomes a narrow obsession with the bone density statistics of healthy middle-aged women. Personal distress is seen as due mostly to a chemical imbalance of serotonin in the brain, an explanation that is as narrow as it is outdated.

This narrowing of focus is making it harder to see the bigger picture of health and disease, sometimes at great cost to the individual and community. If improvements in health were really our primary aim, some of the billions that are currently invested in expensive drugs to lower the cholesterol of the worried well might be far more efficiently spent on enhanced campaigns to encourage them to reduce smoking, increase physical activity and improve their diet.

Marketing fear

There are many different promotional strategies in the selling of sickness, but the common factor among them all is the marketing of fear. The fear of heart attacks (and of ageing itself) was used to sell women the idea that menopause was a medical condition requiring hormone replacement therapy. The fear of suicide among the young is used to sell parents the idea that even a mild depression in their children must be treated with powerful drugs. The fear of an early death is used to classify high cholesterol as a condition requiring a pharmaceutical prescriptions.

Yet the much-hyped medicines sometimes cause the harm they are supposed to prevent. Long-term hormone replacement therapy seemed to increase the risk of heart attacks for women, while antidepressants appear to increase the risk of suicide among the young. At least one blockbuster cholesterol-lowering drug has been withdrawn from the market because it was implicated in deaths. A drug sold as a treatment for common bowel disorders led to constipation so severe that some of its users died; in this case the official government regulators were more interested in protecting drug company profits than the public’s health.

A loosening of advertising regulations in the late 1990s in the US led to unprecedented drug market advertisements that were targeted at ordinary people, who now see an average of 10 such advertisements every day. A similar deregulation in New Zealand had the same effect. Elsewhere in the world the industry is fighting for more ad deregulation.

Over three decades ago the maverick thinker Ivan Illich warned that an expanding medical establishment was medicalising life itself, undermining the human capacity to cope with the reality of suffering and death, and making too many well people into patients. He criticised a medical system “that claims authority over people who are not yet ill, people who cannot reasonably expect to get well, and those for whom doctors have no more effective treatment than that which could be offered by their uncles or aunts” (2).

A decade ago medical writer Lynn Payer described the process she called disease-mongering, in which doctors and drug companies unnecessarily widened the boundaries of illness to recruit more patients and sell more drugs (3). Her writings have become ever more relevant as the industry’s marketing roar becomes louder and its grip on the healthcare system much stronger.

Alan Cassels &
Ray Moynihan

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Original text in English

Ray Moynihan is a journalist specialising in health issues in the ‘British Medical Journal’, The Lancet and The New England Journal of Medicine; Alan Cassels is a pharmaceutical policy researcher at the University of Victoria, British Columbia, Canada. This article is adapted from their book ‘Selling Sickness. How Drug Companies Are Turning Us All into Patients’ (Allen & Unwin, 2005)